Safer Care of the Mechanically Ventilated Patient
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1 Middle East Forum on Quality and Safety in Healthcare Collaborating for Excellence in Patient Care May 2015 QNCC, Doha, Qatar Safer Care of the Mechanically Ventilated Patient
2 Dr. Bill Andrews Deputy Chair for Quality, Department of Anesthesia, ICU and Perioperative Medicine Hamad Medical Corporation Corazu M. Salta BSN RN Quality Lead Coordinator (A) Surgical Intensive Care Unit Hamad General Hospital
3 We have no conflicts of interest
4 Have you observed the changes in the Health Care? Restraint Sedation Mobility Delirium
5 Who is more Vulnerable?
6 How can we keep our Patients Safe while they are on a Mechanical Ventilator?
7 What makes Mechanically Ventilated Patient Most Vulnerable? 1. Immobility 2. Invasion 3. Interstitial Edema 4. Injury 5. Immunosuppression 6. Infections 7. Insanity 8. Impaired Circulation
8 Dr. Bill Andrews
9 Ventilated Patients are Vulnerable!
10
11 Immobilization - Causes
12 Immobilization - Effects
13 Invasion - Causes
14 Invasion - Effects
15 Interstitial Edema - Causes
16 Interstitial Edema - Effects
17 Impaired Circulation - Causes
18 Impaired Circulation - Effects
19 Immunosuppression - Causes
20 Immunosuppression - Effects
21 Infection - Causes
22 Infection - Effects
23 Insanity (Delirium) - Causes
24 Insanity (Delirium) - Effects
25 Injury (Lung) - Causes
26 Injury (Lung) - Effects
27 Corazu M. Salta BSN.RN
28 Early Rehabilitation in the John Hopkins Hospital Dr. Dale Needham
29
30
31 What We Assume Sometimes is Totally the Opposite of What our Patient Really Feels.
32
33 Why Bundles? 5-3evidence based interventions Each with evidence that outcomes improve When done together, proven to improve outcomes* Synergy? *Resar R, Pronovost P, Haraden C, Simmonds T, et al. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Joint Commission Journal on Quality and Patient Safety :)5(31;2005
34 Traditional Bundle Head of the bed 30 O Daily sedative interruption and daily assessment of readiness to extubate Daily oral care with chlorhexidine PUD prophylaxis DVT prophylaxis
35 Next Gen. Bundle - Awaken - Breathing (Allow Spontaneous) - Coordinate Awakening and Breathing - Delirium (Prevent, Detect and Manage) - Exercise and Promote Mobility
36 Dr. Bill Andrews
37 Vol 371 January 12, 2008
38 Vol 371 January 12, 2008
39 American Journal of Respiratory and Critical Care Medicine Volume 191 Number 3 February
40
41 Which sedative? Dexmedetomidine vs.midazolam? JAMA Feb 4;301(5):
42 JAMA Feb 4;301(5):
43 Long-term Cognitive and Psychological Outcomes in the Awakening and Breathing Controlled Trial Jackson Am J Respir Crit Care Med Vol 182. pp , 2010 Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. Mehta JAMA Nov 21;308(19): A randomized trial of protocol-directed sedation management for mechanical ventilation in an Australian intensive care unit. Bucknall Crit Care Med May;36(5):
44 No Sedation? Lancet Feb 6;375(9713):
45 Is Anything NEW Under the Sun? What else can we do to keep our ventilated patients safe??
46 Not much? in What s New? Probiotic prophylaxis to prevent ventilator associated pneumonia (VAP) in children on mechanical ventilation: an open-label randomized controlled trial. Randomized controlled study of probiotics containing Lactobacillus casei (Shirota strain) for prevention of ventilator-associated pneumonia. Significant reduction in ventilator-associated pneumonia with the Venner-PneuX System in high-risk patients undergoing cardiac surgery: the Low Ventilator-Associated- Pneumonia study. Randomized intubation with polyurethane or conical cuffs to prevent pneumonia in ventilated patients. The preventability of ventilator-associated events. The CDC Prevention Epicenters Wake Up and Breathe Collaborative. The impact of abdominal massage administered to intubated and enterally fed patients on the development of ventilator-associated pneumonia: a randomized controlled study. Prevention of ventilator-associated pneumonia and ventilator-associated conditions: a randomized controlled trial with subglottic secretion suctioning.
47 Intensive Care Med (2015) 41:
48 Randomized controlled study of probiotics containing Lactobacillus casei (Shirota strain) for prevention of ventilatorassociated pneumonia. The incidence rates of VAP in the probiotics and control groups were and episodes per 1,000 ventilator-days, respectively (p =.) 0.37 J Med Assoc Thai Mar;98(3):
49 Subglottic suction Low pressure, low volume cuff, no creases Self adjusting tracheal seal monitor Non stick lining S. Gopal et al. / European Journal of Cardio-Thoracic Surgery
50 Subglottic suction Low pressure, low volume cuff, no creases Self adjusting tracheal seal monitor Non stick lining S. Gopal et al. / European Journal of Cardio-Thoracic Surgery
51 Colonization Risk Factors Antibiotic therapy at inclusion HR=0.76 p=0.002 Type of cuff HR=1.0 p=0.6 American Journal of Respiratory and Critical Care Medicine Volume 191 Number 6 March
52 The impact of abdominal massage administered to intubated and enterally fed patients on the development of ventilator-associated pneumonia: a randomized controlled study. Twice daily 15 minute abdominal massages Reduced gastric residual volumes (p<0.05) Reduced abdominal circumference Ventilator associated pneumonia reduced from 31.3% to 6.3% (NS) Int J Nurs Stud Feb;52(2):
53 Crit Care Med 2015; 43:22 30
54 Other Individual Strategies Intermittent sedation Fluid management Avoiding restraints Avoiding unnecessary respiratory support Subglottic suction Better airway care Cuff pressure control, no routine circuit changes Selective Digestive Decontamination Short course prophylactic antibiotic Hand hygiene
55 Corazu M. Salta BSN.RN
56 Time for a new Bundle?
57 Guidelines for the prevention of ventilatorassociated pneumonia and their implementation. The Spanish "Zero-VAP" bundle. They considered 35 potential prevention measures Med Intensiva May;38(4):
58 1. Semi-recumbent position 2. Strict hand hygiene with alcohol-based gels or solutions before airway management 3. Education and training in aspiration of bronchial secretions 4. Daily sedation vacation and assessment of weaning and extubation 5. Availability of weaning protocols 6. Early tracheostomy 7. Non-invasive mechanical ventilation 8. Microbiological surveillance of crosscontamination and infection 9. Instillation of normal saline prior to endotracheal suctioning 10. Ventilator tubing change 11. Route of endotracheal intubation. Orotracheal vs. nasotracheal 15 Elements 12. Type of airway humidification. Preference of heat moisture exchanger or heated humidifier 13. Physiotherapy 14. Positive end-expiratory airway pressure (PEEP) of 5 8cmH2O vs. Zero end-expiratory pressure (ZEEP) in patients without lung injury 15. Enteral feeding: route of administration and gastric residual volumes. Use of Prokinetics
59 1. Endotracheal tube cuff pressure monitoring 2. Subglottic secretion drainage 3. Polyurethane-cuffed endotracheal tubes 4. Polyurethane-cuffed endotracheal tubes with subglottic secretion drainage 5. Silver-coated endotracheal tubes 6. High-volume, low-pressure endotracheal tube cuff 7. Small caliber feeding tubes 8. Aspiration of tracheobronchial secretions with closed vs. open systems 9. Endotracheal tube biofilm removal 13 Elements device (Mucus Shaver ) 10. Kinetic bed therapy 11. Airway filters 12. Water-soluble gel lubrication of the endotracheal tube 13. Tooth brushing
60 . 1 Selective decontamination of the digestive tract. 2 Selective oropharyngeal decontamination. 3 Short course of intravenous antibiotic. 4 Oral hygiene with chlorhexidine. 5 Nebulized antibiotics. 6 Antibiotic cycling. 7 Probiotics 7 Elements
61 Med Intensiva May;38(4):
62 Now it s YOUR Turn! 15 minutes to do what the Spanish took months to do! Rate each intervention on a 1-5 scale for: Effectiveness, Safety, Feasibility, Cost We don t have real data, so we are going to be creative Choose 4-5 of the highest priority interventions
63 Dr. Bill Andrews
64 Spanish Results 153 Med Intensiva May;38(4):
65 Spanish Results 153 Med Intensiva May;38(4):
66 Spanish Results 153 Med Intensiva May;38(4):
67 Spanish Results 153 Med Intensiva May;38(4):
68 Spanish Results Med Intensiva May;38(4):
69 Spanish Results Med Intensiva May;38(4):
70 Spanish Results Med Intensiva May;38(4):
71 Spanish Results Med Intensiva May;38(4):
72 Spanish Results Med Intensiva May;38(4):
73 Spanish Results Med Intensiva May;38(4):
74 Spanish Results Med Intensiva May;38(4):
75 Spanish Results Med Intensiva May;38(4):
76 Summary 1. Immobility 2. Invasion 3. Interstitial Edema 4. Injury 5. Immunosuppression 6. Infections 7. Insanity 8. Impaired Circulation
77 Summary we can do better
78 How? - Awaken - Breathing (Allow Spontaneous) - Coordinate Awakening and Breathing - Delirium (Prevent, Detect and Manage) - Exercise and Promote Mobility And more...
79 It has been our pleasure! Thank you all
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